Abdominal pain | |
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Other names | Stomach ache, tummy ache, belly ache, belly pain, gastralgia, stomach pain |
Abdominal pain can be characterized by the region it affects. | |
Specialty | Gastroenterology, general surgery |
Causes | Serious: Appendicitis, perforated stomach ulcer, pancreatitis, ruptured diverticulitis, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated spleen or liver, ischemic colitis, ischaemic myocardial conditions [1] Common: Gastroenteritis, irritable bowel syndrome [2] |
Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important. [3]
Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. [2] About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy. [2] In a third of cases, the exact cause is unclear. [2]
The onset of abdominal pain can be abrupt, quick, or gradual. Sudden onset pain happens in a split second. Rapidly onset pain starts mild and gets worse over the next few minutes. Pain that gradually intensifies only after several hours or even days has passed is referred to as gradual onset pain. [4]
One can describe abdominal pain as either continuous or sporadic and as cramping, dull, or aching. The characteristic of cramping abdominal pain is that it comes in brief waves, builds to a peak, and then abruptly stops for a period during which there is no more pain. The pain flares up and off periodically. The most common cause of persistent dull or aching abdominal pain is edema or distention of the wall of a hollow viscus. A dull or aching pain may also be felt due to a stretch in the liver and spleen capsules. [4]
The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). [2] More common in those who are older, ischemic colitis, [5] mesenteric ischemia, and abdominal aortic aneurysms are other serious causes. [6]
Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause. [7] The underlying cause may involve infection, inflammation, vascular occlusion or bowel obstruction. [7]
The pain may elicit nausea and vomiting, abdominal distention, fever and signs of shock. [7] A common condition associated with acute abdominal pain is appendicitis. [8] Here is a list of acute abdomen causes:
Surgical causes | Source: [7] Inflammatory
Mechanical
Vascular
Referred painSource: [9]
|
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Medical causes | Source: [7] Diabetic ketoacidosis (DKA). Familial Mediterranean fever (FMF). |
Gynecological causes | Source: [11] Pelvic inflammatory disease (PID) and abscess. Hemorrhagic ovarian cyst. Adnexal or ovarian torsion. |
A more extensive list includes the following:[ citation needed ]
The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include: [12] [13]
Region | Blood supply [14] | Innervation [15] | Structures [14] |
---|---|---|---|
Foregut | Celiac artery | T5 - T9 | Pharynx Proximal duodenum |
Midgut | Superior mesenteric artery | T10 – T12 | Distal duodenum Proximal transverse colon |
Hindgut | Inferior mesenteric artery | L1 – L3 | Distal transverse colon Superior anal canal |
Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut. [14] The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas. [14] The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon. [14] The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal. [14]
Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves. [16] The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific. [17] Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved. [17]
A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.
The process of gathering a history may include: [18]
After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam. [18]
Additional investigations that can aid diagnosis include: [20]
If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include: [20]
The management of abdominal pain depends on many factors, including the etiology of the pain. Some dietary changes that some may participate in are: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Some at home strategies like these can avoid future abdominal issues, resulting in the need of professional assistance. [21] In the emergency department, a person presenting with abdominal pain may initially require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or vomiting. [22] Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl). [22] Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes. [22] Patients presenting to the emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid (examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and lidocaine. [22] After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain. [22] Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success. [23] Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.[ citation needed ]
Below is a brief overview of abdominal pain emergencies.
Condition | Presentation | Diagnosis | Management |
---|---|---|---|
Appendicitis [24] | Abdominal pain, nausea, vomiting, fever Periumbilical pain, migrates to RLQ | Clinical (history and physical exam) Abdominal CT | Patient made NPO (nothing by mouth) IV fluids as needed General surgery consultation, possible appendectomy Antibiotics Pain control |
Cholecystitis [24] | Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign | Clinical (history and physical exam) Imaging (RUQ ultrasound) Labs (leukocytosis, transamintis, hyperbilirubinemia) | Patient made NPO (nothing by mouth) IV fluids as needed General surgery consultation, possible cholecystectomy Antibiotics Pain, nausea control |
Acute pancreatitis [24] | Abdominal pain (sharp epigastric, shooting to back), nausea, vomiting | Clinical (history and physical exam) Labs (elevated lipase) Imaging (abdominal CT, ultrasound) | Patient made NPO (nothing by mouth) IV fluids as needed Pain, nausea control Possibly consultation of general surgery or interventional radiology |
Bowel obstruction [24] | Abdominal pain (diffuse, crampy), bilious emesis, constipation | Clinical (history and physical exam) Imaging (abdominal X-ray, abdominal CT) | Patient made NPO (nothing by mouth) IV fluids as needed Nasogastric tube placement General surgery consultation Pain control |
Upper GI bleed [24] | Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia | Clinical (history & physical exam, including digital rectal exam) Labs (complete blood count, coagulation profile, transaminases, stool guaiac) | Aggressive IV fluid resuscitation Blood transfusion as needed Medications: proton pump inhibitor, octreotide Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
Lower GI bleed [24] | Abdominal pain, hematochezia, melena, hypovolemia | Clinical (history and physical exam, including digital rectal exam) Labs (complete blood count, coagulation profile, transaminases, stool guaiac) | Aggressive IV fluid resuscitation Blood transfusion as needed Medications: proton pump inhibitor Stable patient: observation Unstable patient: consultation (general surgery, gastroenterology, interventional radiology) |
Perforated Viscous [24] | Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomen | Clinical (history and physical exam) Imaging (abdominal X-ray or CT showing free air) Labs (complete blood count) | Aggressive IV fluid resuscitation General surgery consultation Antibiotics |
Volvulus [24] | Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation) Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting | Clinical (history and physical exam) Imaging (abdominal X-ray or CT) | Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy) Cecal: General surgery consultation (right hemicolectomy) |
Ectopic pregnancy [24] | Abdominal and pelvic pain, bleeding If ruptured ectopic pregnancy, the patient may present with peritoneal irritation and hypovolemic shock | Clinical (history and physical exam) Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG Imaging: transvaginal ultrasound | If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation If patient is stable: continue diagnostic workup, establish OBGYN follow-up |
Abdominal aortic aneurysm [24] | Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal mass | Clinical (history and physical exam) Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography | If patient is unstable: IV fluid resuscitation, urgent surgical consultation If patient is stable: admit for observation |
Aortic dissection [24] | Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur | Clinical (history and physical exam) Imaging: Chest X-ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE | IV fluid resuscitation Blood transfusion as needed (obtain type and cross) Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker) Surgery consultation |
Liver injury [24] | After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder pain | Clinical (history and physical exam) Imaging: FAST examination, CT of abdomen and pelvis | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy |
Splenic injury [24] | After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank pain | Clinical (history and physical exam) Imaging: FAST examination, CT of abdomen and pelvis | Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy If patient is stable: medical management, consultation of interventional radiology for possible arterial embolization |
One well-known aspect of primary health care is its low prevalence of potentially dangerous abdominal pain causes. Patients with abdominal pain have a higher percentage of unexplained complaints (category "no diagnosis") than patients with other symptoms (such as dyspnea or chest pain). [25] Most people who suffer from stomach pain have a benign issue, like dyspepsia. [26] In general, it is discovered that 20% to 25% of patients with abdominal pain have a serious condition that necessitates admission to an acute care hospital. [27]
Abdominal pain is the reason about 3% of adults see their family physician. [2] Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%. [28]
More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED). [29] Compared to younger patients with the same complaint, their length of stay is 20% longer, they need to be admitted almost half the time, and they need surgery 1/3 of the time. [30]
Age does not reduce the total number of T cells, but it does reduce their functionality. The elderly person's ability to fight infection is weakened as a result. [31] Additionally, they have changed the strength and integrity of their skin and mucous membranes, which are physical barriers to infection. It is well known that older patients experience altered pain perception. [32]
The challenge of obtaining a sufficient history from an elderly patient can be attributed to multiple factors. Reduced memory or hearing could make the issue worse. It is common to encounter stoicism combined with a fear of losing one's independence if a serious condition is discovered. Changes in mental status, whether acute or chronic, are common. [33]
Unique clinical challenges arise when pregnant women experience abdominal pain. First off, there are many possible causes of abdominal pain during pregnancy. These include intraabdominal diseases that arise incidentally during pregnancy as well as obstetric or gynecologic disorders associated with pregnancy. Secondly, pregnancy modifies the natural history and clinical manifestation of numerous abdominal disorders. Third, pregnancy modifies and limits the diagnostic assessment. For instance, concerns about fetal safety during pregnancy are raised by invasive exams and radiologic testing. Fourth, while receiving therapy during pregnancy, the mother's and the fetus' interests need to be taken into account. [34]
Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.
Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.
Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.
Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea, diarrhea or constipation. Fever or blood in the stool suggests a complication. People may experience a single attack, repeated attacks, or ongoing "smoldering" diverticulitis.
Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.
Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the formation of adhesions presenting with the clinical syndrome of right upper quadrant (RUQ) pain.
A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the vitelline duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.
Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory organs of digestion, the liver, gallbladder, and pancreas.
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.
Diverticular disease is when problems occur due to diverticulosis, a benign condition defined by the formation of pouches (diverticula) from weak spots in the wall of the large intestine. This disease spectrum includes diverticulitis, symptomatic uncomplicated diverticular disease (SUDD), and segmental colitis associated with diverticulosis (SCAD). The most common symptoms across the disease spectrum are abdominal pain and bowel habit changes such as diarrhea or constipation. Otherwise, diverticulitis presents with systemic symptoms such as fever and elevated white blood cell count whereas SUDD and SCAD do not. Treatment ranges from conservative bowel rest to medications such as antibiotics, antispasmodics, acetaminophen, mesalamine, rifaximin, and corticosteroids depending on the specific conditions.
Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.
An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination.
Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. People with this condition often describe it as "feeling bloated". Affected people often experience a sensation of fullness, abdominal pressure, and sometimes nausea, pain, or cramping. In the most extreme cases, upward pressure on the diaphragm and lungs can also cause shortness of breath. Through a variety of causes, bloating is most commonly due to buildup of gas in the stomach, small intestine, or colon. The pressure sensation is often relieved, or at least lessened, by belching or flatulence. Medications that settle gas in the stomach and intestines are also commonly used to treat the discomfort and lessen the abdominal distension.
Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply (ischemia). Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.
An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.
A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.
Epiploic appendagitis (EA) is an uncommon, benign, self-limiting inflammatory process of the epiploic appendices. Other, older terms for the process include appendicitis epiploica and appendagitis, but these terms are used less now in order to avoid confusion with acute appendicitis.
Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.
Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating.
The human abdomen is divided into quadrants and regions by anatomists and physicians for the purposes of study, diagnosis, and treatment. The division into four quadrants allows the localisation of pain and tenderness, scars, lumps, and other items of interest, narrowing in on which organs and tissues may be involved. The quadrants are referred to as the left lower quadrant, left upper quadrant, right upper quadrant and right lower quadrant. These terms are not used in comparative anatomy, since most other animals do not stand erect.